Submitted by Sanni Bundgaard, Advisor for Care for Women Survivors, International Rescue Committee
Imagine a health center that is open, stocked with vaccines and fully staffed, in a region where measles is known to be endemic. But only three children are vaccinated every month. Would you then conclude that measles is not a big problem? Would you interpret the small numbers of immunized children as an absence of need? Would you accept the job as done?
When those questions are applied to clinical care for survivors of gender-based violence (GBV), the answers are often yes. Evidence suggests that 1 in 5 women experience sexual violence during displacement — and this does not include consequences of intimate partner violence, trafficking, female genital mutilation, forced marriage and lack of access to resources. Sexual violence is one of the most invasive types of violence and has the potential to devastate an individual’s health, safety and well-being and break down communities.
Despite this immense need and numerous international guidelines, protocols, hashtags and research, clinical care for GBV survivors remains one of the most neglected health interventions during humanitarian emergencies. A recent evaluation found that most women who experience sexual violence and other types of gender-based violence do not find quality care or referral options. Addressing these gaps in humanitarian settings requires addressing the fact that resources are scarce and technical capacity among health providers is often limited.
It also requires addressing another area of neglect: humanitarian agencies working in health aren’t addressing a root cause of these gaps. Survivors often avoid seeking care because they risk experiencing more harm from disclosure, than from the physical or psychological consequences they suffered. Women are often unaware of the treatment, prevention and services available to them. Aid agencies and health providers need to realize that simply ensuring that trained staff, clinical protocols and drugs are available to provide services does not necessarily create real access, nor does it break down the barriers caused by gender inequality.
At least one emerging approach has proven to make services more accessible, but continues to be largely bypassed. Rather than simply sit by and wait for GBV survivors to seek out care, active identification of GBV survivors — also known as universal screening — means health care providers ask women simple, direct questions about their experiences with intimate partner violence, sexual violence, exploitation, forced abortion and other types of GBV when they seek health services. Depending on their answers, they are offered care or appropriate referrals based on their needs and wishes. A number of different humanitarian actors have been exploring active identification of GBV survivors as one way to increase utilization of lifesaving GBV services.
Over the past few years, the International Rescue Committee has been exploring screening as a health sector intervention in humanitarian settings. While we have faced challenges around limited funding and excessive health provider workload in humanitarian settings, our experience has demonstrated that screening questions used in safe, comfortable and culturally appropriate ways increased the number of survivors referred for health and psychosocial services by up to 400%. We implemented screening among conflict-prone and refugee communities in Kenya, South Sudan and the Democratic Republic of Congo. So far, it has succeeded in many contexts. The screening intervention did more than just increase the uptake in survivors receiving medical and psychosocial care — women and the healthcare providers overwhelmingly found it acceptable. Furthermore, it began to erode other barriers, reducing negative attitudes among health providers and increasing awareness of the negative impact of GBV in communities.
The expansion of this intervention is currently hindered by the fact that the World Health Organization did not endorse it in its recommendations. In 2014, the WHO decided in their clinical and policy guidelines that GBV screening should not be implemented. The WHO working group concluded that there was insufficient evidence to support the idea that GBV screening leads to a reduction in intimate partner violence or an improvement in quality of life or health outcomes for women.
Points about insufficient evidence at that time were fair enough. But in order to continue moving forward, we need to ask ourselves what criteria is appropriate for an intervention to be recommended. The issue of violence against women is complicated and women often have little influence on violence. Is it realistic for a single intervention to decrease GBV or intimate partner violence, which is so deeply rooted in gender inequality and social norms? With enough barriers standing between survivors and care, the international community — including the WHO — should reconsider the standards that decide whether GBV interventions become an international recommendation. We must ask ourselves, what are the consequences of black-listing interventions that have not yet been explored in a given context?
The better questions to explore would be: Do survivors feel that GBV screening improved and facilitated access to health and psychosocial services? What is the impact of the health sector openly addressing GBV and ensuring knowledge of services available and timely care is provided for women in a safe and confident manner? How does intense training, supervision and GBV awareness influence health providers’ ability to provide quality care and referrals?
Screening will not solve all the challenges that impede survivors of gender-based violence from receiving appropriate care. But it does belong on a short list of interventions that, if done correctly and accompanied by primary prevention interventions, are proven to make life-saving services accessible to those that need them the most.
The international community undoubtedly faces questions that are complicated. How to address the root causes of gender-based violence and intimate partner violence is among them. But other questions are not. We know that asking seven direct questions may help more women who have experienced gender-based violence receive the help that they need. Not to oversimplify a complicated matter, but that seems like good reason to ask. Doesn’t it?
Sanni Bundgaard is the International Rescue Committee’s Advisor for Care for Women Survivors. A report on the IRC and Johns Hopkins University screening project can be found here. Contact her at Sanni.Bundgaard@rescue.org or follow her on Twitter at @sannibundgaard.